Enhanced recovery after elective spinal surgery: an Australian pilot study.

Background: The principles of enhanced recovery after surgery (ERAS) aim to reduce the physiological stress of surgery which in turn improve clinical and health economic outcomes. There is ample evidence in literature supporting ERAS methodologies in other surgical specialties, but its adoption in spinal surgery, especially in Australia remains in infancy. The aim of this project is to describe the early experience with an evidence-based ERAS pathway for simple spine surgery, a first of its kind in Australia. Methods: An ERAS protocol was designed using an evidenced-based review of the literature. The authors then conducted a prospective cohort analysis looking at outcome of patients undergoing elective spinal (lumbar and cervical) decompression surgery under ERAS principles by a single surgeon on the Westmead Hospital Campus between March 2021 to May 2023. Primary outcomes were patient length of stay (LOS), patient reported pain and disability scores and complications (including readmissions within 30 days and re-operation within 6 months). Secondary outcomes included predictors of failure for same-day discharge. Results: A total of 52 patients underwent spinal decompression surgeries under the ERAS protocol. Overall 43 out of 52 patients (83.7%) were successfully discharged on the same day as their surgery. Patient reported outcomes were improved at 6 weeks and 6 months confirming durability of intervention. The rates of complications were similar to literature reported rates for simple lumbar or cervical decompression procedures and there were no readmissions within 30 days or re-operations within 6 months of surgery. Being of non-English speaking background [odds ratio (OR) =6.08, P=0.04] and from home alone (OR =10.25, P=0.03) were predictors of failure of same day discharge in this small cohort. Conclusions: Implementation of ERAS protocols for simple spinal decompression surgeries is feasible and produces durable improved patient outcomes while reducing LOS in hospitals. Patient social factors can be predictive of lack of compliance.

Radiotherapy versus limb-sparing surgery alone in low-grade soft-tissue sarcoma of the extremity and trunk wall: a systematic review and meta-analysis.

Current guidelines recommend the use of radiotherapy in the management of intermediate and high-grade soft-tissue sarcoma of the extremity and trunk wall. Its use in low-grade sarcoma is less clear. To date there have been no pooled data analyses regarding its role in this context. Its use is not without complications and therefore must be justified. We aim to assess the oncological impact of radiotherapy versus limb-sparing surgery alone in this subset of sarcoma. Medline, EMBASE and Cochrane's databases were searched from 1982 to present. Studies on or having a subgroup analysis of low-grade soft tissue sarcoma, with a radiotherapy and a surgery only arm were included. Outcomes included local recurrence and overall survival. Patients were at least 16 years of age with primary de-novo sarcoma who had not undergone prior resection or treatment. Those undergoing concomitant therapy were excluded. Data extraction was performed independently by two reviewers. Results were pooled using a random-effects model and presented as a forest plot. Primary outcome measures included local recurrence and overall survival. Eleven unique studies were included, consisting of two RCTs and nine non-randomized studies. Overall, there were 12 799 patients. Four studies were included in meta-analysis and the overall pooled effect showed a limited role of radiotherapy in overall survival outcomes when compared to limb-sparing surgery alone HR 1.00 [0.83-1.20] P = 0.41. Descriptive analysis suggests there is limited role of radiotherapy in improving local recurrence outcomes. This study suggests there is limited role for radiotherapy versus limb-sparing surgery alone in low-grade soft-tissue sarcoma. These findings strongly suggest there is lack of high-quality data and that further research must be undertaken prior to forming any strong conclusions regarding the management of low-grade soft-tissue sarcoma. Demonstrating a role for radiotherapy may help improve the quality of excisional margins and thus potentiate limb-sparing surgery.

Simulations found within-subject measurement variation in glycaemic measures may cause overdiagnosis of prediabetes and diabetes.

OBJECTIVE: To determine the impact of test measurement variation on misclassification of prediabetes and diabetes in the US adult population. STUDY DESIGN AND SETTING: Data from adults with no prior diagnosis of diabetes in the 2015 to 2016 National Health and Nutrition Examination Survey (NHANES) were used to simulate populations of US adults eligible for screening. Estimates of measurement variation were applied to each simulated individual's true values to generate observed values for up to five repeated screens. RESULTS: UNDERDIAGNOSIS: For 100,000 people assessed according to ADA or USPSTF guidelines, no people with true values in the diabetes range would be underdiagnosed as normal after one screen, and between 64 and 138 people would be misclassified with prediabetes after five re-screens (depending on guideline and test used). OVERDIAGNOSIS: For 100,000 people assessed according to the guidelines, between 1,602 and 2,233 people with true values in the normal range would be over diagnosed with prediabetes after 3 re-screens. A further 627 to 1,672 people with true values in the prediabetes range would be over diagnosed with diabetes after 5 re-screens. CONCLUSION: Measurement variation may cause overdiagnosis of prediabetes and diabetes, as well as apparent "progression" or "regression" of either condition.